Extracranial vertebral artery aneurysm with neurofibromatosis. Endovascular treatment by detachable balloon

External carotid artery-radial artery-vertebral artery bypass for surgical treatment of radiculopathy caused by an extracranial vertebral artery aneurysm: A case report and review of the literature

Background

Vertebral artery (VA) aneurysm is a rare etiology of cervical radiculopathy and there is a paucity of case reports described in the literature.

Case Description

We describe a case of a patient with no history of trauma presenting with a large right VA aneurysm at the C5-C6 level compressing the C6 nerve root and causing a painful radiculopathy. The patient underwent successful external carotid artery-radial artery-VA bypass followed by trapping of the aneurysm and decompression of the C6 nerve root.

Conclusion

VA bypass is an effective tool for treatment of symptomatic large extracranial VA aneurysms and a rare cause of radiculopathy.

Endovascular management of V3 segment vertebro-vertebral fistula: case management and literature review

Vertebro-vertebral fistula involving the V3 segment of the vertebral artery is a rare vascular pathology which is either spontaneous or traumatic in origin. We describe a post-operative traumatic vertebro-vertebral fistula in a 47-year old lady with NF-1. We review reported cases of V3 segment vertebrovertebral fistula for their incidence, aetiology, clinical presentation, treatment and outcomes using an illustrative case. Traumatic V3 segment vertebrovertebral fistula is predominantly managed with parent vessel occlusion. Per the algorithm presented, we suggest endovascular management of non-traumatic fistula be based on the anatomical variance of the contralateral vertebral artery.

Successful Endovascular Trapping for Symptomatic Thrombosed Giant Unruptured Aneurysms of the V1 and V2 Segments of the Vertebral Artery: Case Report and Literature Review

A thrombosed giant aneurysm of the V1 and V2 segments of the vertebral artery (VA) is rare. Therefore, there is controversy regarding its optimal treatment. A case of a symptomatic giant VA aneurysm located in the V1 to V2 segments on the left treated successfully by endovascular trapping of the VA is reported. A 68-year-old woman presented with swelling in the left anterior neck. Computed tomography angiography (CTA) showed a giant aneurysm measuring 47 × 58 × 47 mm³ in the left neck. Ten days after her first visit, she presented with sudden onset of left anterior neck pain. Repeated CTA showed a partial thrombus in the aneurysm. Angiography showed two thrombosed giant aneurysms located in the V1 to V2 segments of the left VA. After endovascular trapping for the aneurysms, the anterior neck pain resolved and the aneurysm gradually shrank. This case demonstrates that endovascular surgery is better than open surgery because it is less invasive. When performing endovascular treatment, trapping will be an alternative strategy for a symptomatic giant thrombotic aneurysm of the V1 and V2 segments of the VA if the patient can tolerate ischemia.

Chronic fusiform extracranial vertebral artery aneurysm with recurrent posterior circulation emboli: Case report and review of the literature

We report a case of a 64-year-old man with a fusiform right extracranial vertebral artery aneurysm, spanning over half the extra-cranial V2 (foraminal) segment, presenting with recurrent multi-focal posterior circulation embolic ischaemic stroke. The patient was treated with endovascular embolisation of the right vertebral artery to prevent further thrombo-embolic events. Distal and proximal occlusion of the aneurysmal vertebral artery was performed with a micro-vascular plug with partial aneurysm sack embolisation to aid thrombosis and reduce the risk of recanalisation. Two months post procedure MR angiography confirmed successful aneurysm occlusion with no post-procedural complication. The patient returned to his normal independent life. Endovascular treatment with vessel sacrifice is an effective treatment with low morbidity and we believe the MVP device to be a efficacious option in the vertebral artery.

The endovascular management of neurofibromatosis-associated aneurysms: A systematic review

BACKGROUND

Neurofibroblastoma (NF) or Von Recklinghausen disease, is an autosomal dominant disorder affecting one in 3000 individuals. Cardinal features of NF include multiple café-au-lait macules, benign neurofibromas, and iris hamartomas. Albeit less common, vascular lesions of medium and large-sized arteries and veins are a well-recognized complication, which can lead to fatal consequences such as rupture.

METHOD

A systematic review was conducted as per the Preferred Reporting Instructions for Systematic Reviews and Meta-analysis (PRISMA) guidelines utilizing PubMed, EMBASE, and Cochrane databases.

RESULTS

There were 59 articles identified involving 66 patients (mean age 44.3 ± 30 years), of which 89% had neurofibromatosis type 1. There were 63.6% of patients who presented with aneurysm rupture, 33.3% presented with intact symptomatic aneurysms, and 3.1% presented with intact asymptomatic aneurysms. Anatomically, 4.5% of patients suffered from intracranial aneurysms; 12.1% suffered from visceral artery aneurysms (including hepatic, superior mesenteric, gastroduodenal and renal arteries), and other patients suffered from aneurysms within the chest, abdomen, pelvis, upper limbs and neck. Amongst the various endovascular procedures, coiling was performed in 83.3% of cases. There were 12 covered stents employed in 10 patients (18.2%), of which 7 were balloon-expandable grafts; 2 were self-expandable graft; 3 were not mentioned. The rates of major and minor complications were 15% and 6% respectively, with 4 cases (6%) of perioperative death. On a mean follow-up of 15 months (range 1.5-72 months), two patients developed a distant vascular lesion from the treated lesion.

CONCLUSION

Endovascular management is safe and effective even in hemodynamically unstable neurofibroblastoma patients at all ages. Vascular tree screening should be conducted in clinically suspicious patients to prevent fatal aneurysmal complications. A formal meta-analysis could not be performed due to the lack of randomized controlled trials.

Neurofibromatosis Type 1-Associated Extracranial Vertebral Artery Aneurysm Complicated by Vertebral Arteriovenous Fistula After Rupture: Case Report and Literature Review

BACKGROUND

Extracranial vertebral artery aneurysm related to neurofibromatosis type 1 (NF1) is rare. Aneurysmal rupture typically induces such symptoms as cervical hematoma, hemothorax, and hypotension. Here we report a case of ruptured extracranial vertebral artery aneurysm in a patient with NF1 who, rather than cervical hematoma, hemothorax, or hypotension, developed a vertebral arteriovenous fistula (AVF) after aneurysm rupture.

CASE DESCRIPTION

A 35-year-old woman with a family history of NF1 presented with sudden-onset right neck and shoulder pain. Computed tomography angiography showed a right extracranial vertebral artery aneurysm. She had neither a cervical hematoma nor hypotension; however, angiography showed an AVF secondary to aneurysmal rupture. The patient was treated with endovascular coil embolization to prevent re-rupture. Postoperatively, her right neck and shoulder pain improved, and she was discharged without further neurologic deficits.

CONCLUSIONS

This patient's clinical course suggests that if there is minimal bleeding from an NF1-associated ruptured extracranial vertebral artery aneurysm, then typical symptoms, such as cervical hematoma, hemothorax, and hypotension, may be absent. Thus, ruptured extracranial vertebral artery aneurysm should be considered in the differential diagnosis of patients with NF1 with sudden-onset radiculopathy, even in the absence of typical symptoms. The detection of a vertebral AVF provides a useful clue to the diagnosis of aneurysm rupture in such cases.

Ruptured extracranial vertebral artery aneurysm associated with neurofibromatosis type 1. Case report

A 31-year-old man presented with a ruptured right extracranial vertebral artery aneurysm associated with neurofibromatosis type 1, manifesting as acute onset of right neck and shoulder pain, and right supraclavicular mass. Three-dimensional computed tomography angiography showed a large aneurysm involving the right extracranial vertebral artery associated with a pseudoaneurysm. The aneurysm was successfully treated by transarterial endovascular trapping with detachable coils. Extracranial vertebral artery aneurysm is rare, but the mortality of ruptured cases is extremely high, so early diagnosis and early treatment are important. The present case shows that endovascular treatment was very effective.

Vertebral artery aneurysms and cervical arteriovenous fistulae in patients with neurofibromatosis 1

Vascular involvement in the setting of neurofibromatosis type 1(NF1) has been well described. However, the coexistence of NF1 with vertebral artery (VA) aneurysms and arteriovenous fistulae (AVFs) is a rare occurrence. A 60-year-old female with NF1 and other severe comorbidities presented with acute respiratory insufficiency caused by a ruptured large VA aneurysm and an associated AVF that required emergent intubation and eventual repair through endovascular techniques that resolved her symptoms. A detailed description of this case and a comprehensive review of the literature are also presented.

Brachial artery aneurysm rupture in a patient with neurofibromatosis: a case report

Peripheral vascular manifestations of neurofibromatosis are rare but may result in fatal haemorrhaging when they rupture. Surgeons should be aware of this life-threatening condition. We report a case of 35-year-old woman with neurofibromatosis who presented with a swollen and tender mass around her right arm. Angiography revealed 2 aneurysms in the brachial artery. Surgical occlusion revealed a large amount of clotted blood within the subfascial space, and the bleeding point was identified as a pinpoint opening in the aneurysm. The brachial artery abutting the aneurysm and the surrounding soft tissues was extremely brittle and fragile, with massive oozing during dissection. The brachial artery was irreparable and was resected after ligation of the artery and surrounding soft tissues and the aneurysm. Despite an uneventful recovery, the patient died on day 4.

Extracranial vertebral artery involvement in neurofibromatosis type I. Report of four cases and literature review

SUMMARY

Neurofibromatosis type 1 (NF-1) is one of the most common inherited diseases and as an autosomal dominant genetic disorder results from NF-1 gene mutation with 100% penetration and wide phenotypic variability. The disease can involve a wide variety of tissues derived from all three embryonic layers. NF-1 vasculopathy has been described primarily in peripheral arteries, but arteries supplying the CNS may also be involved. Of those, extracranial vertebral involvement is the commonest and most important. A series of four patients with NF-1 and vascular disease of the vertebral artery is described with a review of the pathophysiology, vascular phenotypes, their management and the pertinent literature.

PSEUDOTUMORAL PRESENTATION OF A CERVICAL EXTRACRANIAL VERTEBRAL ARTERY ANEURYSM IN NEUROFIBROMATOSIS TYPE 1

OBJECTIVE

Neurofibromatosis Type 1 (NF1) is known to be associated with vascular lesions. Association with an extracranial vertebral artery aneurysm is very rare. We report the case of such an aneurysm mimicking a cervical neurofibroma in NF1.

CLINICAL PRESENTATION

An 18-year-old woman with previously diagnosed NF1 presented with a C6 radiculopathy. There were no clinical features suggesting a vascular origin for the lesion. The computed tomographic and standard magnetic resonance imaging scans showed a C5–C6 contrast-enhancing lesion responsible for bony erosion. Subsequent, magnetic resonance angiography and digital subtraction angiography diagnosed the lesion as a C5–C6 vertebral artery aneurysm.

INTERVENTION

The lesion was treated by endovascular occlusion of both the aneurysm and the parent vertebral artery with an initial immediate disappearance of the pain.

CONCLUSION

This case serves as a reminder of the importance of ruling out a vertebral artery aneurysm with angiography when managing cervical lesions in patients with NF1.

Extracranial vertebral artery aneurysm associated with neurofibromatosis type 1. A case report

SUMMARY

Extracranial vertebral artery aneurysm associated with neurofibromatosis (NF1) is very rare. The aneurysm was successfully treated by endovascular trapping of the aneurysm and proximal vertebral artery with coils.

EXTRACRANIAL VERTEBRAL ARTERY ANEURYSM RUPTURED INTO THE THORACIC CAVITY WITH NEUROFIBROMATOSIS TYPE 1: CASE REPORT

OBJECTIVE AND IMPORTANCE

We are sometimes involved in the care of patients with neurofibromatosis Type 1 because of the associated disorders of cervicocerebral vessels. However, extracranial vertebral artery aneurysm in neurofibromatosis Type 1 is very rare. We present the first reported case of a rupture of an extracranial vertebral artery aneurysm into the thoracic cavity in a patient with neurofibromatosis Type 1.

CLINICAL PRESENTATION

A 52-year-old woman who presented with a decrease in left-sided grip and numbness of the left upper limb was admitted. During history taking, she developed shock. Radiological examination revealed that a left extracranial vertebral artery aneurysm had ruptured into the thoracic cavity. With consciousness decreasing gradually because of hemorrhagic shock, the patient became comatose.

INTERVENTION

Balloon occlusion of the vertebral artery proximal to the aneurysm was performed and surgical ligation was attempted, but cardiac arrest occurred immediately after the beginning of surgery, and the patient died. The vertebral artery proximal to the aneurysm was removed for pathological examination.

CONCLUSION

In this case, the changes noted were interpreted as changes showing fragility of the vascular wall secondary to neurofibromatosis Type 1. Patients with neurofibromatosis Type 1 exhibit disorders of cervicocerebral vessels, and in some cases progression may follow a violent course. Periodic follow-up of such patients and early diagnosis are important.

Tratamento endovascular de fístula arteriovenosa vertebral espontânea em criança: relato de caso

Fístulas espontâneas da artéria vertebral são raras malformações arteriovenosas entre a artéria vertebral e um vaso circunvizinho. Relatamos um caso de fístula arteriovenosa, não traumática, em uma criança de 9 anos de idade, submetida a tratamento por via endovascular. Sob anestesia geral e controle fluoroscópico, empregou-se a técnica endovascular para posicionar um balão destacável de látex, dessa forma ocluindo totalmente o trajeto fistuloso. Resolução clínica e angiográfica foi obtida, e não houve complicações relacionadas com o procedimento de embolização. O resultado observado comprova que a embolização especialmente oclusão com balões descartáveis, tornou-se o tratamento padrão para esta enfermidade.

Diagnosis and endovascular treatment of vertebral arteriovenous fistulas in neurofibromatosis type 1

SUMMARY

We present diagnostic problems, strategies, techniques and material selection for endovascular treatment of high flow arteriovenous fistula (AVF) of tortuous and fragile vertebral artery (VA) with neurofibromatosis type 1 (NF1). Diagnosis of NF1 was easy in four of our cases because of neurofibromatosis, skin pigmentation and various skeletal abnormalities. These stigmas of NF1 were lacking in one case, and the only clue to the diagnosis was ovoid bone defects of the skull vault. Diagnosis was made by performing biopsy of scalp neurofibromas incidentally found on CT. In two initial cases, venous varix were packed with coils by transvenous approach after the transarterial embolisation failed to completely cure the fistula. In three recent cases, blood flow through the fistula was markedly reduced as an initial step by placing detachable coils into the distal and proximal stumps of the afferent VA. Then a liquid adhesive was injected under systemic hypotension to completely occlude the fistula. Control angiography revealed that the AVFs were completely occluded in all cases. Longterm angiographical and clinical status have been stable in all cases. Trying to attain complete occlusion of fistulas using detachable balloons is not an appropriate treatment option for high flow fistulas situated on markedly dilated, tortuous and fragile VAs of patients with NF1. Also, trapping of fistulas is not justified because of the numerous potential feeding pedicles, and makes the following procedure difficult.

Vertebral arteriovenous fistula associated with neurofibromatosis type I misdiagnosed as a giant aneurysm

SUMMARY

A 59-year-old man with neurofibromatosis type 1 (NF1) presented with bruits and neck pain due to a space occupying lesion in the right neck tissue. Digital subtraction angiography (DSA) showed an arteriovenous fistula (AVF) of the right extracranial vertebral artery (VA) with a giant venous pouch and an intracranial berry aneurysm of the right middle cerebral artery (MCA). First, the MCA aneurysm was surgically clipped, then the patient was treated by embolisation with coils. The coils were placed transarterially from the left VA resulting in a partial thrombosis of the venous pouch. Complete closure was achieved secondarily by retrograde transvenous catheterization. Etiology and treatment modalities are discussed.

Vertebral arteriovenous fistula that developed in the same place as a previous ruptured aneurysm: a case report

BACKGROUND

Aneurysms of the extracranial vertebral artery (VA) and vertebral arteriovenous fistulas (VAVFs) are relatively rare diseases. The most frequent cause of both diseases is trauma. Atraumatic lesions are less common. Presented here is a case of atraumatic AVF of the extracranial VA that developed in the same location as a previous ruptured aneurysm of the ipsilateral VA that was originally treated by proximal occlusion 11 years earlier.

METHODS

A 40-year-old woman presented with a massive hematoma in the upper posterior neck region caused by the rupture of an extracranial VA aneurysm. Proximal occlusion of the VA was performed by use of a detachable balloon. She enjoyed good health for 11 years, then she noticed a pulsatile bruit. Angiograms revealed an AVF between the left VA that was fed by collateral circulation and the paravertebral venous plexus. Incidentally found were soft tissue masses in the left retroauricular and the right suboccipital regions. Also, skull X-ray films showed multiple bony defects. Biopsy of the subcutaneous mass was performed in the hope of obtaining clues as to which pathological processes had weakened the artery.

RESULTS

As direct transarterial access to the fistula was out of the question, the fistulous compartment of the paravertebral venous plexus was tightly packed with multiple platinum coils effected by the transfemoral approach. A histological examination of the specimen revealed features of a neurofibroma, and a diagnosis of neurofibromatosis Type 1 was established.

CONCLUSIONS

In this case, transvenous embolization of the VAVF was successfully performed. The fragility of the arterial wall, related to neurofibromatosis Type 1, was considered to contribute to the development of the aneurysm and AVF.

Aneurysm of the major vessels in neurofibromatosis

The case of a patient who presented with a ruptured aneurysm of the brachial artery and type I neurofibromatosis is presented. Angiography revealed a ruptured aneurysm of the brachial artery in the middle of the upper arm. Repair of the artery with autogenous vein grafting was impossible due to the extremely brittle brachial artery and accompanying veins. The blood supply distal to the aneurysm was secured by collaterals, and the aneurysm, including a relatively long portion of the brachial artery and veins adjacent to the aneurysm, was resected. The patient died of massive hemorrhage from the subclavian artery of the involved side 9 days postoperatively. Histological and immunohistological examinations of the tissues involved in the ruptured aneurysm were conducted. The resected brachial artery and veins were surrounded by hypertrophied tissue which tested positive for S-100 protein and negative for desmin and action. These findings suggest that the origin of the proliferating tissue was not mesodermal dysplasia, but neurofibroma occurring near or in the vessels. A ruptured aneurysm in a patient with neurofibromatosis should not be treated with reconstruction of the vessels. The treatment of choice is surgical or endovascular occlusion of the vessels involved.

Cervical vertebral arteriovenous fistula balloon embolization in a patient with neurofibromatosis type 1

The authors present a patient with neurofibromatosis type 1 associated with cervical kyphosis, a cervical vertebral arterial fistula, and contralateral vertebral arterial occlusion. The fistula was successfully treated with detachable balloons.

Neurovascular manifestations of heritable connective tissue disorders. A review

BACKGROUND

Heritable disorders of connective tissue are recognized in a small minority of patients with neurovascular diseases. In this report, we review the neurovascular manifestations of four heritable connective tissue disorders: Ehlers-Danlos syndrome, Marfan's syndrome, osteogenesis imperfecta, and pseudoxanthoma elasticum, as well as two other systemic disorders with potential vascular manifestations: neurofibromatosis and polycystic kidney disease.

SUMMARY OF REVIEW

Typical neurovascular complications of Ehlers-Danlos syndrome are carotid-cavernous fistulae, intracranial aneurysms, and cervical artery dissections. Arterial dissections and intracranial aneurysms cause the majority of neurovascular symptoms in Marfan's syndrome. Neurovascular disease is uncommon in osteogenesis imperfecta, although carotid-cavernous fistulae and vertebral artery dissections have been reported. Neurovascular disease in pseudoxanthoma elasticum is characterized by intracranial aneurysms and cerebral ischemia caused by premature arterial occlusive disease. Intracranial occlusive arterial disease is the most common neurovascular manifestation of neurofibromatosis, followed by cervical arteriovenous fistulae and aneurysms and intracranial aneurysms. Intracranial aneurysms are the hallmark of polycystic kidney disease.

CONCLUSIONS

Recognition of an underlying generalized connective tissue disorder may be of considerable importance, although marked phenotypic heterogeneity often complicates the diagnosis of these disorders. Conversely, the association of certain neurovascular anomalies with generalized connective tissue disorders and recognition of their basic molecular defect may offer clues to the etiology and pathogenesis of these neurovascular diseases in general.

Neurofibromatosis presenting as a severe systemic vasculopathy

In a boy with neurofibromatosis type 1 (NF-1), hypertension, septic infection of an aneurysm in the deltoid muscle, bowel infarction, multiple arterial aneurysms and venous thrombosis occurred within a period of 6 weeks. Histologically, vascular neurofibromatosis of the small vessels of the gut was found. This unusual occurrence of a multitude of clinical features within a few weeks was caused by vascular neurofibromatosis. Awareness of this condition in patients with NF-1 may help the paediatrician to avoid unnecessary diagnostic procedures and to initiate appropriate symptomatic therapy.